EMHware :: Pathstone Mental Health

Pathstone Mental Health

1338 Fourth Avenue

St. Catharines Ontario L2S 0G1

Phone: (905) 688-6850,
Fax: (905) 688-9951

Referral Type:

New Referral

Submit

Save

Referral:

Physician Referral Form ID

Date:

2025-03-29 02:28

Status:

Draft

Attachment(s):

( Max File Size is 256 MB )

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Patient/Client's Personal Information

If the client is 16+, are the parents aware of the referral?

First Name

Last Name

Preferred Name

Health Card

Address

City

Postal Code

Phone (Home/Main)

Permission to call?

Phone (Alt)

DOB

Age

Years Months

Gender

Parent's Name

(1)

Resides with

Custody Type

Family Physician

Telephone

Psychiatrist

Telephone

Referral Information

Referral Source

Referred by

Date

Physician's Billing #

Risks

Reason for Request (Required):

Reason(s) for Request

Service(s) Requested:

	Counselling/Therapy
	Psychiatric Consult (for Diagnostic Clarification and/or Medication follow-up)

Medication

	Medication
	Allergies

Consent and Agreement

I/, WE THE UNDERSIGNED AGREE TO THE EXCHANGE OF PERSONAL HEALTH INFORMATION BETWEEN CLIENT AND PATHSTONE MENTAL HEALTH. I, FURTHER AGREE TO THE PERSONAL HEALTH INFORMATION EXCHANGE BETWEEN PATHSONE MENTAL HEALTH AND NIAGARA HEALTH BE COLLECTED, USED, OR DISCLOSED FOR THE PURPOSE OF REFERRAL, TREATMENT PLANNING, COORDINATION AND FOLLOW UP SERVICES/SUPPORTS. I ALSO AGREE TO A SOCIAL WORKER CALLING ME FOR THE PURPOSE OF COMPLETING AN INTAKE.

Date